Rebecca F Hamm1, Rinad Beidas2,3,4,5, Sindhu K Srinivas1, Lisa D Levine1. 1. Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. 2. Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. 3. Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. 4. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. 5. Penn Implementation Science Center at the Leonard Davis Institute (PISCE@LDI), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Abstract
OBJECTIVE: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity. STUDY DESIGN: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome. RESULTS: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity. CONCLUSIONS: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
OBJECTIVE: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity. STUDY DESIGN: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome. RESULTS: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity. CONCLUSIONS: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
Authors: Steven Clark; Michael Belfort; George Saade; Gary Hankins; Darla Miller; Donna Frye; Janet Meyers Journal: Am J Obstet Gynecol Date: 2007-11 Impact factor: 8.661
Authors: Lisa D Levine; Katheryne L Downes; Samuel Parry; Michal A Elovitz; Mary D Sammel; Sindhu K Srinivas Journal: Am J Obstet Gynecol Date: 2017-12-07 Impact factor: 8.661